The costs and cost effectiveness of providing first-trimester, medical and surgical safe abortion services in KwaZulu-Natal Province, South Africa

Abstract

Background: Despite a liberal abortion law, access to safe abortion services in South Africa is challenging for many women. Medication abortion was introduced in 2013, but its reach remains limited. We aimed to estimate the costs and cost effectiveness of providing first-trimester medication abortion and manual vacuum aspiration (MVA) services to inform planning for first-trimester service provision in South Africa and similar settings.

Methods: We obtained data on service provision and outcomes from an operations research study where medication abortion was introduced alongside existing MVA services in public hospitals in KwaZulu-Natal province. Clinical data were collected through interviews with first-trimester abortion clients and summaries completed by nurses performing the procedures. In parallel, we performed micro-costing at three of the study hospitals. Using a model built in Excel, we estimated the average cost per medical and surgical procedure and determined the cost per complete abortion performed. Results are presented in 2015 US dollars.

Results: A total of 1,129 women were eligible for a first trimester abortion at the three study sites. The majority (886, 78.5%) were eligible to choose their abortion procedure; 94.1% (n = 834) chose medication abortion. The total average cost per medication abortion was $63.91 (52.32-75.51). The total average cost per MVA was higher at $69.60 (52.62-86.57); though the cost ranges for the two procedures overlapped. Given average costs, the cost per complete medication abortion was lower than the cost per complete MVA despite three (0.4%) medication abortion women being hospitalized and two (0.3%) having ongoing pregnancies at study exit. Personnel costs were the largest component of the total average cost of both abortion methods.

Conclusion: This analysis supports the scale-up of medication abortion alongside existing MVA services in South Africa. Women can be offered a choice of methods, including medication abortion with MVA as a back-up, without increasing costs.

Fig 1. Decision tree for medication abortion and MVA service outcomes, based on operations research study [17].

MA = medication abortion, MVA = manual vacuum aspiration, LTFU = lost to follow up NB: Unscheduled visits among MA women may have occurred before or after the scheduled follow-up visit. For simplicity, all are shown here before the follow-up visit.